Health Behaviors Among School-Aged Children: a

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Health Behaviors Among School-Aged Children: a Cross Sectional Study in Lebanese Private Schools R. Abdo, R. Zeenny & P. Salameh

International Journal of Mental Health and Addiction ISSN 1557-1874 Int J Ment Health Addiction DOI 10.1007/s11469-016-9677-z

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Author's personal copy Int J Ment Health Addiction DOI 10.1007/s11469-016-9677-z

Health Behaviors Among School-Aged Children: a Cross Sectional Study in Lebanese Private Schools R. Abdo 1 & R. Zeenny 2 & P. Salameh 1,2

# Springer Science+Business Media New York 2016

Abstract There is insufficient data on health-risk behaviors of school students in Lebanon. The objective of our study is to provide data about the prevalence of cigarette and waterpipe smoking as well as alcohol drinking patterns among school students, focusing on gender differences and searching for tobacco and alcohol uses’ predictors. The dissemination of such information is required in order to promote health and assist the local authorities in Lebanon in designing tobacco and alcohol control prevention programs with a particular attention to youth. Using a convenient sample of Lebanese students, aged between 11 and 20 years, a cross-sectional study was carried out in nine private schools in Beirut and Mount Lebanon. A standardized questionnaire was used for collecting data related to socio-demographic characteristics, tobacco and alcohol consumption, entourage consumption, and health-related behaviors. Additional questions related to the general perception of personal health and life satisfaction, social activities, physical activity and sedentary behavior, school environment, family and peer relationships were also included in the questionnaire. The summary of responses is analyzed using two methods: bivariate and multivariable analyses. Among 1982 participants, 10.3, 16.9, and 42.4 % are cigarette smokers, waterpipe smokers, and alcohol consumers respectively. Higher rates of smoking and alcohol consumption are found out among boys as opposed to girls (p < 0.001). We identified that a significant association exists Key messages • Considerable proportions of substance users have been found among adolescents in private schools in Lebanon where 10.3, 16.9 and 42.4 % are identified as current cigarette, WP and alcohol consumers respectively. • The study shows that there is a clear correlation among WP, cigarette and alcohol consumption. • All three behaviors are associated with age, time spent with friends, entourage and energy drink consumption. • Anti-tobacco smoking and anti-excessive drinking intervention strategies, which target children in early years at high schools, are recommended in order to limit health-risk behaviors among this vulnerable age group.

* R. Abdo [email protected]

1

Laboratory of Clinical and Epidemiological Research, Faculties of Pharmacy & of Public Health, Lebanese University, Beirut, Lebanon

2

Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Jbeil, Lebanon

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between tobacco and alcohol consumption based on age, district, socioeconomic status, connectivity with family, family and entourage influence, days spent with friends, drunkenness and binge drinking, energy drink consumption, weight status, self-rated health, electronic media communication, and last quarter average (aOR going from 0.50 till 0.87 for protective factors and inverse relationships and from 1.19 till 5.80 for positive associations). Substantial proportions of school students in Lebanon adopt risky behaviors. Health-promotion activities need to be established in order to decrease the occurrence of such behaviors and prevent deleterious health outcomes. Keywords Schools . Risky . Tobacco . Cigarette . Waterpipe . Alcohol The vast majority of changes in physical, psychological, and social human interactions occur during the adolescent period (WHO 2011c). Adolescence is a crucial stage in the life-course of a human being and can be considered the most critical one since adolescent practices and behaviors, particularly those picked up in school, may predict behaviors and health status in early adulthood (El-Roueiheb et al. 2008; Guo et al. 2000; WHO 2011a). Various unhealthy behaviors such as smoking and alcohol use are usually initiated during the developmental periods of adolescence or childhood (WHO 2011a). Tobacco consumption is considered by the World Health Organization as one of the most urgent epidemics to tackle. Accordingly, smoking is responsible for consistent rise in preventable deaths in the world, secondary to non-communicable diseases. It kills nearly 6 million people and causes hundreds of billions of dollars of economic damage worldwide each year (WHO 2012). Along the same lines, smoking has reached epidemic rates in Arabic-speaking countries (Maziak et al. 2013). Tobacco is not only consumed in the form of cigarettes; waterpipe (WP) (also known as argileh, hubble-bubble, hookah, and shisha) is another form of smoking, which is commonly used among individuals across all age groups worldwide (ElRoueiheb et al. 2008). Although the vast majority of smoking-related deaths occur among middle-aged and elderly people, smoking behavior is undeniably established in adolescence (DHHS 1994). Young smokers may acquire the habit (Järvelaid 2004; Jason et al. 1999) and become addicted before reaching adulthood (BMA 2007). This may sequentially lead to heavy consumption (DHHS 1994), more dependence (BMA 2007), and more tobacco-related health problems (Currie et al. 2004; Henderson 2008). Smoking may lead to short-term health problems in young people, including reduced lung function, increased asthmatic problems, coughing, wheezing and shortness of breath, reduced physical fitness, and greater susceptibility to and severity of respiratory illness (DHHS 1994). Furthermore, smoking may cause longterm health problems such as lung cancer, respiratory diseases (including COPD and bronchitis), and cardiovascular diseases (including stroke and coronary heart disease) (U.S. DHHS 2010; U.S. DHHS 2014). On the other hand, alcohol is the most commonly used psychoactive substance in the world. It constitutes one of the leading causes of death and disability (Rehm et al. 2009; WHO 2011b). Alcohol abuse causes 3.2 % of all deaths worldwide annually and accounts for 4.0 % of the global disease burden each year (WHO 2011b). Drinking prevalence increases dramatically during adolescence (Adlaf et al. 2005; Currie et al. 2008; Hibell et al. 2004; Johnston et al. 2006). Adolescence is a time for exploration, and alcohol use is a common behavior which many adolescents would want to experiment with (Simons-Morton et al. 2009). In fact, commercial advertising associates alcohol with a variety of benefits that appeal to young people, including social camaraderie, masculinity, sexual attraction, and adventure. Media

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images targeting the young generation rarely show any of the harmful health and social consequences of underage drinking, such as embarrassment, hangovers, accidents, neglecting responsibilities, getting into fights or arguments, missing school, driving after drinking, interpersonal violence, risky sexual behavior, and attempted suicide (Atkin 1993; Miller et al. 2007). Some long-term effects of alcohol use during adolescence may include increased risk of alcohol dependence, learning and memory impairments, liver diseases, stroke and cancer (NIAAA 2000). Alcohol and nicotine addiction mostly occur together. The concomitant use of alcohol and tobacco has clearly more damaging effects than either agent consumed alone. The use of these substances among adolescents is a public health concern and has been studied extensively in many countries around the world. Over the last 10 years, therapeutic aspects and motivational strategies have been considerably improved. However, alcohol and nicotine addiction still represents major medical and social problems (Lesch et al. 2011). In Lebanon, there is little data on health-risk behaviors among school children in the country. Only three studies about cigarette and WP smoking had been published (ElRoueiheb et al. 2008; Saade et al. 2008; Zahlan et al. 2014). El-Roueiheb et al. determined the prevalence in 2002–2003 of WP and/or cigarette smoking among adolescent school students – in intermediate and secondary classes – in public and private schools within Greater Beirut. However, the multivariable analysis that they performed studied only the relationship between tobacco smoking and three independent variables: gender, type of school, and class. Saade et al.’s study was limited to the descriptive comparison of tobacco use prevalence between 2001 and 2005, the factors that influence tobacco use, the susceptibility to initiate smoking in the following year, and the cessation indicators. The study sample included students, aged between 13 and 15 years, enrolled in both, private and public schools. On the other hand, Zahlan et al. recent study presented prevalence of substance use (cigarette, WP and alcohol), however, the study’s objective was intended to explore the association between WP tobacco smoking and the nonmedical use of psychoactive prescription drugs among high school students attending private and public schools in Greater Beirut. Moreover, there is no published literature on alcohol use among school children to date. Therefore, this study aims to assess cigarette and WP smoking as well as alcohol drinking patterns in school students comparing the prevalence of these behaviors by gender and determining factors correlated with regular cigarette, WP and alcohol use. The provision of this information will raise public awareness and hopefully induce behavioral changes in the target audience. We will, therefore, communicate the study results to officials in Lebanon (Ministry of Public Health and Ministry of Education and Higher Education), as well as schools’ relevant stakeholders. They will be encouraged to adopt a joint program of awareness targeting school children. On the long run, laws must be amended to integrate activities that promote health behaviors in academic curricula.

Methods Study Design A cross-sectional study was carried out between April and June 2014. Using convenience sampling, a group of adolescents, who are attending private schools in Beirut or Mount Lebanon, were enrolled in this study. Targeted participants were students aged between 11 and 20 years. A sample size of at least 1500 individuals was targeted for an adequate power necessary to enable bivariate and multivariable analyses.

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Data Collection Out of 24 private schools approached, nine (6 schools in Mount Lebanon and 3 in Beirut) authorized the study protocol and provided the required consent for it. The study was accordingly approved as exempt. All students in selected classes, who were physically present on the day when the survey was administered, were eligible to participate. The study questionnaire was given in hard copy in order to be filled out by students in their usual classrooms. The purpose of the study was written at the beginning of the questionnaire and was elucidated orally in class by the investigator(s). The participants provided oral consent by voluntarily indicating their wish to receive the questionnaire and participate in the study. A returned filled out questionnaire was considered an additional evidence of oral consent. Written consent was not needed since the study does not entail any harm to participants. The students were assured that their participation is voluntary and anonymous while they can skip any questions or stop anytime. Students were also assured that their answers shall remain confidential and cannot be traced back to them. The investigator confirmed that the data will be analyzed in aggregate with no identifiers or tracers to the individuals or schools. At the end of the process, the completed questionnaires were placed in closed boxes and sent for data entry. Out of 2150 distributed questionnaires, 2076 (96.6 %) were returned, out of which 94 (4.5 %) were removed due to being almost empty or incomplete. The rate of students who refused to participate was calculated to be less than 0.3 %.

Study Instrument Questionnaire Content A self-administered anonymous questionnaire, available in French and English languages (depending whether the school is French or English -educating), was used for data collection. The questionnaire is an international standardized tool adapted from the HBSC study in different countries (Godeau et al. 2012; Iannotti 2012) and has been adjusted to the Lebanese population. The different questions, which have been used to assess tobacco smoking and alcohol drinking behaviors, included items about the past and present smoking and drinking practices, frequency, age of initiation, and social context. Current consumer is defined as someone who has been smoking cigarettes and/or WP and has been consuming alcohol at least once during the last month. Socio-demographic and -economic characteristics, eating and drinking consumption and behavior habits, family and peer relationships, tobacco (cigarette and/or WP) and alcohol concomitant consumption, entourage consumption, social activities, self-rated health and ladder of life, weight status and body image, physical activity and sedentary behavior, school environment and bullying were the assessed predictors to draw the consumers profiles. BSubstance abuse^ and BSexual behavior^ topics have been removed to meet the schools’ requirements for approval. Before distribution, the questionnaire was pilottested on 20 school students in order to come up with a clear set of questions for the study.

Socioeconomic Status The SES of respondents was assessed using the promiscuity index (number of individuals per house divided by the number of rooms per house (except bathrooms, toilets and balconies) as a surrogate measure. The obtained number was subsequently divided into tertiles: tertile 1 (Lowest SES), tertile 2 (Medium SES) and tertile 3 (Highest SES), according to which individuals were classified.

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Anthropometric Measures To validate the self-reported measures, height and weight were measured in a randomly selected subsample of 243 students using calibrated balance for weight measurement and stadiometer for height measurement. Four simple regression equations were generated to validate the self-reported values; correlation coefficients along with their associated t-test were performed: Boys : Measured weight ¼ 0:995  Reported weight þ 3:175 ðp < 0:001Þ Measured height ¼ 0:862  Reported height þ 23:509 ðp < 0:001Þ Girls : Measured weight ¼ 0:950  Reported weight þ 5:230 ðp < 0:001Þ Measured height ¼ 0:627  Reported height þ 60:563 ðp < 0:001Þ The predicted values have then been used as corrected height and weight to calculate the corrected Body Mass Index (BMI). The BMI, calculated as weight in kilograms over height in meters squared, is used to evaluate obesity (normal weight, overweight and obese) (Luciano et al. 2003; Magarey et al. 2003). We used the cut-off values taken from the International Obesity Taskforce for BMI of children aged 2–18 years to define obesity and overweight (Magarey et al. 2003).

Statistical Analysis Data was entered, cleaned, managed, and analyzed using SPSS, version 17.0. A sample of 45 questionnaires was completely checked for errors. Data entry showed high reliability with an error rate of less than